Overview of Abortion
Abortion is a commonly performed medical procedure among women. In 2014, in the US, for every 5 pregnancies, at least one ended in abortion. Shockingly, approximately one in four women in the US is likely to have an abortion during their lifetime. It’s a worldwide trend too, as one in every four pregnancies globally ends in abortion. It’s crucial that everyone understands how widespread abortions are, the options available, the safety measures taken, the restrictions in place, and the difficulties in accessing this healthcare service, to ensure that everyone receives the best possible care.
A study by the National Academies of Sciences, Engineering, and Medicine in 2018 confirmed all forms of abortion, including medication and suction abortions, to be safe and effective. They found that the only factors that decrease the safety of abortions are those that limit access to them. It’s also very important to know that first-trimester abortions don’t pose any long-term risk to a woman’s ability to have children in the future, the occurrence of ectopic pregnancies (when a fertilized egg implants outside the uterine wall), spontaneous abortion (which is the medical term for a miscarriage), or breast cancer. They also found that abortions don’t cause any risk to a woman’s mental health.
Abortion can be done either using certain medications or through a surgical procedure, often referred to as a suction abortion. A woman may choose to have an abortion due to personal reasons or because there may be complications with the fetus. Before an abortion, certain health checks may be performed including blood tests, screening for sexually transmitted infections, monitoring of pregnancy hormone levels, and an ultrasound to ensure the pregnancy is located within the uterus. An abortion using medication can be completed at home, while a suction abortion is usually done in a clinic or hospital, with local anesthesia given to manage pain, and sometimes light sedation.
Anatomy and Physiology of Abortion
The female reproductive system is generally made up of external and internal parts. The external parts, sometimes referred to as the external genitalia, include the following:
- Mons Pubis: This is a rounded fatty area that sits over the pubic bones, right where they join.
- Labia Majora: These are two skin folds that extend from the Mons Pubis downwards.
- Labia Minora: This part is located inside the Labia Majora.
- Bartholin Gland: This gland is very similar to the bulbourethral gland in men. It creates lubrication right at the entrance of the vagina.
- Clitoris: This is a very small, sensitive part of the vagina that is responsible for feelings of pleasure and stimulation.
- Vulva: This term is used to collectively describe all of the external female genitalia.
The internal parts of the female reproductive system, also known as the internal genitalia, include the following:
- Ovaries: These are the organs that produce eggs during a typical menstrual cycle.
- Fallopian Tubes: Also known as uterine tubes, their job is to carry the eggs from the ovaries to the uterus, or womb. They are a critical part of understanding pregnancy because if a pregnancy occurs outside of the uterus, it most frequently happens in the fallopian tubes.
- Uterus: Also known as the womb, this organ is sensitive to hormones and is where a fertilized egg will implant and develop.
- Cervix: This is the lower part of the uterus and serves as a link between the uterus and vagina.
- Vagina: This is the lowest part of the female genital tract, extending from the cervix to the outer part of the body.
Knowing the normal structure of these parts can help in managing complications of medical abortions and performing surgical abortions.
Why do People Need Abortion
According to the latest guidelines from the National Abortion Federation in 2020, it’s crucial that patients considering an abortion receive unbiased counseling on all their options. This discussion should include not just having an abortion but also the possibility of continuing the pregnancy, becoming a parent, adoption, and ending the pregnancy. If the patient decides to terminate the pregnancy, then they need to understand the procedure thoroughly, including its benefits, risks, and specifics.
An early medication abortion is one option. It’s non-invasive, meaning there’s no surgical procedure needed. There are also no risks associated with anesthesia. It’s a safe option up to the 11th week of pregnancy and allows the patient to maintain privacy and control. This method often uses drugs like mifepristone, misoprostol and in rare cases, methotrexate. Medication abortion is also safe and effective after the first trimester, as long as the care is provided by a trained clinician in a fully equipped setting. For later stages of pregnancy, induced fetal disappearance might be necessary.
Aspiration or surgical abortion is another option. This method involves a procedure that uses instruments inserted into the vagina, cervix, and uterus to remove the pregnancy. The procedure is typically short. Aspiration abortion might be needed if the medication abortion is unsuccessful or if the woman experiences heavy bleeding during the medication abortion. According to the 2020 National Abortion Federation Guidelines, the risk of needing an aspiration procedure post-medication abortion is between 2-9% for pregnancies more than 63 days along, and even less, between 1 and 3%, when the second dose of misoprostol is used. Aspiration or surgical abortion might also be necessary if a suspected molar pregnancy is present. A molar pregnancy is a rare condition where abnormal tissue grows inside the uterus instead of a baby.
When a Person Should Avoid Abortion
There are several reasons why a person might not be able to use medication to have an abortion:
– If a person has an intrauterine device (IUD), a small contraceptive device placed inside the uterus, it may need to be removed before the abortion.
– If a person is allergic to the medication used in the abortion procedure.
– If a person has chronic adrenal failure, a condition in which the adrenal glands don’t produce enough of certain types of hormones. This is especially true for people who are on long-term treatment with corticosteroids, a type of drug that reduces inflammation in the body.
– If a person is suspected to have an ectopic pregnancy, a dangerous condition where the pregnancy grows outside the uterus.
– If a person has a disorder related to bleeding or clotting.
– If a person is on anticoagulants (commonly known as blood thinners), which prevent blood from clotting. The only one exception is aspirin.
– If a person’s body isn’t stable enough to maintain proper levels of blood and oxygen (a condition known as hemodynamic instability).
– If a person has inherited porphyria, a group of disorders that can cause skin or nervous system problems.
Conditions like anemia, seizures, asthma treated with steroid inhalers, obesity, breastfeeding, HIV or AIDS, and sexually transmitted infections are not reasons to avoid a medication abortion.
For people with coagulopathy (a condition that affects the blood’s ability to clot) or any other bleeding disorder, extra care should be taken, but these conditions do not mean that a person can’t have a surgical or aspiration abortion. In the case that there’s no evidence of fetal tissue after a surgical abortion, the hormone levels should be monitored to rule out ectopic pregnancy or pregnancy of unknown location.
Equipment used for Abortion
In the procedure of an aspiration abortion, several different tools are used:
The first is a vacuum aspirator. This is a device that draws out the tissue from the uterus using suction. A manual version can also be used alongside a special syringe that can hold up to 60 cc (cubic centimeters) of fluid, which is locked in place to prevent spillage.
A cannula is another tool used. This is a thin tube that can be inserted into the body to draw out or deliver fluids.
A specimen cup is used to hold the tissue that is removed. This might be used later for medical testing.
Another tool, the graves speculum, is used by doctors to widen the vagina for better visibility and access during the procedure.
The single tooth tenaculum is a type of clamp with a hook that helps stabilize the cervix (the lower part of the uterus).
Ring forceps with cotton are used to grasp or hold body tissues and other materials during the procedure.
Small polyp forceps are used to remove small growths, known as polyps, from inside the uterus. The Pratt cervical dilators are tools used to open the cervix more, allowing the doctor better access.
Gauze, a type of thin, translucent fabric, is usually used to clean the area or stop any minor bleeding that might occur. A curette is a surgical instrument that has a loop at the end and is used for scraping or scooping tissue, in this case from inside of the uterus.
Preparing for Abortion
When a woman becomes pregnant and decides not to continue with the pregnancy, an abortion can be a solution. There are two ways this can be done: medication abortion or surgical abortion.
For a medication abortion, few steps are taken before proceeding with the abortion. Firstly, the date of the last menstrual period (LMP) is noted down to calculate how far along the pregnancy is. If the woman can’t remember her LMP, an ultrasound will be used to determine the age of the pregnancy. The ultrasound is only required when the LMP is not known.
Next, a detailed health history is taken, including any prior medical conditions, medications she is taking, any allergies, and whether she’s used any substances. She might also need to have a physical exam, though this depends on her symptoms and medical history. If her LMP is certain and she’s healthy, she won’t need any laboratory tests or a pelvic exam. Otherwise, some tests may be recommended, such as glucose for patients with insulin-dependent diabetes, a blood test (INR) for those on blood thinners, Rhesus D testing for rhesus-negative individuals, or tests for sexually transmitted infections like gonorrhea or chlamydia if she’s younger than 25 or at an increased risk.
The medication used for this kind of abortion is a combination of mifepristone and misoprostol, which is more effective than using misoprostol alone.
Sometimes, side effects can occur due to the medicines. Mifepristone can cause vaginal bleeding and misoprostol can cause nausea, vomiting, diarrhea, low-grade fever, and muscle aches. If the medicines are vomited within 15 to 30 minutes of use, another dose may have to be taken. Medication can also be given to manage the side effects. It’s also important to note that the bleeding can last from 1 to 45 days and can be heavy at times. If the bleeding is heavier than 2 pads per hour for over 2 hours, she should seek medical help.
Before the procedure, she will need to understand the process, the risks involved, potential side effects of the medications, and provide her signed consent.
On the other hand, for a surgical abortion, some different steps are taken. After the doctor takes her medical history and confirms the pregnancy, an ultrasound is usually done to find the location of the pregnancy. Her vital signs will also be checked and a physical exam is conducted if her symptoms and history suggest it’s needed. She will be organized with all the necessary information and support she needs for the procedure.
How is Abortion performed
Medical Abortion
The Mifepristone/Misoprostol protocol
Medication abortion includes two types of medicines. The first one, Mifepristone, is swallowed as a single 200mg tablet. This can be done in the doctor’s office or at home. The second one, Misoprostol, is used in one of the three ways:
1. Buccally: You put four 200mcg tablets in your mouth, between the gum and cheek. After 30 minutes, you swallow them. This is done 24 to 48 hours after Mifepristone.
2. Vaginal: You can insert four 200mcg tablets of Misoprostol in your vagina, 6 to 48 hours after taking Mifepristone.
3. Sublingual: Place two to four 200mcg tablets of Misoprostol under the tongue for 30 minutes.
You might need to take a second dose of Misoprostol if the pregnancy is more advanced. Non-prescription painkillers like NSAIDs can also be used for managing pain at home.
You’ll need to get in touch with your healthcare provider if you:
1. Bleed heavily, soaking through two or more pads in two or more consecutive hours.
2. Experience severe pain that isn’t relieved by the medication prescribed.
3. Have a fever over 100.4 degrees Fahrenheit (38 C) for more than 24 hours after taking Misoprostol.
4. Haven’t bled within 24 hours of taking Misoprostol.
5. Feel nauseous, vomit, have diarrhea, or abdominal pain more than 24 hours after taking Misoprostol.
The doctor can tell if the abortion was successful by using a home pregnancy test or a blood test, which checks the level of the pregnancy hormone, HCG. A reduction of this hormone in your blood means that the abortion was successful.
Surgical Abortion
Surgical or aspiration abortion can be performed up to 16 weeks into pregnancy. The procedure consists of dilating the cervix and using an aspirator (a suction device) to empty the uterus. The length of the procedure may vary but it usually takes about 5 to 10 minutes. If you’re pregnant for more than 16 weeks, the doctor might suggest dilatation and evacuation, which requires adequate dilation of the cervix.
Remember, all procedures can carry risks and it’s important to discuss potential outcomes and plans for your health with your healthcare provider.
Possible Complications of Abortion
Complications can sometimes occur following a medication abortion. These are the main ones, along with options for dealing with them:
1. Some people experience heavy bleeding or severe cramping. This can be managed with medications like misoprostol and NSAIDs (non-steroidal anti-inflammatory drugs), uterine aspiration (a procedure to empty the uterus), or in severe cases, a blood transfusion.
2. In some cases, the medication abortion may not work. If this happens, uterine aspiration or repeating the misoprostol treatment might be needed.
3. A condition known as endometritis can occur, which is an infection causing fever, abdominal and pelvic pain, vaginal discharge, and tenderness. This could be identified more than 24 hours after the misoprostol. In these situations, aspirating the uterus, if there’s retained pregnancy tissue, and antibiotics as per the Centers for Disease Control (CDC) guidelines might be suggested.
In these cases, immediate hospital admission could be needed, especially if the person appears unstable. Antibiotic treatment may also be required to manage infection.
Ectopic pregnancy is a serious condition where the pregnancy occurs outside the uterus that requires further treatment or referral.
After an aspiration abortion (a procedure to remove the pregnancy from the uterus), several complications could occur:
1. Someone might experience a vasovagal episode, which is a sudden drop in heart rate and blood pressure leading to fainting. This can be managed with cold compresses, elevating the legs, certain body exercises, and atropine, a medication that’s used in emergencies.
2. Heavy bleeding, which could require various treatments, like:
– Tone: a uterine massage and medication that stimulates contraction of the uterus.
– Tissue: Checking for any leftover pregnancy tissue in the uterus.
– Trauma: Locating the source of bleeding and managing any injuries.
– Thrombin: Checking the person’s bleeding history and doing certain tests.
– Treatment: An IV fluid and using a catheter to apply pressure to the uterus to stop the bleeding.
– Transfer: If necessary, transferring the patient to the hospital for further treatment.
3. Perforation, which is a rare injury to the uterus, is managed based on the patient’s stability. Stable patients can undergo the procedure under ultrasound guidance with some medications. If unstable, the patient should be transferred.
4. Incomplete abortion might require giving more misoprostol or reaspirating the uterus if the person is experiencing bleeding, pain, or signs of infection.
5. If blood accumulates in the uterus after the procedure, it can cause pain and rectal pressure. Resolving it may require uterine aspiration or medication.
6. Endometritis can be treated with antibiotics, an ultrasound, or an aspiration procedure. It might also be necessary to test for infections like gonorrhea and chlamydia.
7. If there’s a suspected ectopic pregnancy, the patient might be referred to a hospital for treatment with medication or surgery.
What Else Should I Know About Abortion?
If a woman’s pregnancy test comes back positive, it is important for her to understand all the options she has, and she should be advised about these in a fair and impartial way during her appointment. Abortion is generally a safe and successful procedure. Healthcare professionals need to be knowledgeable about how common abortion is, the restrictions in place, and the challenges that can arise when trying to access abortion services. Their goal should be to provide safe care to patients who decide to have an abortion.
